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Cornerstone Surgery Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 May 2020

We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: safe; effective, responsive and well-led.

Because of the assurance received from our review of information we carried forward the ratings for the following key question: Caring.

 

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We rated the practice as requires improvement for providing safe services because:

We found that:

  • There was limited evidence of shared learning from significant events.

The practice did not have robust systems in place to keep patients safe.

  • Safeguarding policies did not provide staff with the information required to enable staff to deal with all kinds of abuse such as female genital mutilation (FGM) and radicalisation (PREVENT) and the policy in place was not readily available, however, staff had the appropriate level of safeguarding training and access to the safeguarding lead however.

The practice did not have appropriate systems in place for the safe management of medicines, in particular:

  • Medicine management systems did not reflect legal requirements.
  • Paper prescriptions were not stored securely, and uncollected prescriptions were not dealt with in a timely manner.
  • Systems for checking the emergency medicines needed to be tightened and systems to monitor the prescription of high- risk medicines were not robust.

Systems for managing staff needed to be strengthened in particular:

  • The practice had not ensured the immunisation status of staff was checked in-line with best practice guidance.

  • Training in some key safety topics had not been completed or were not up to date for example, sepsis; fire safety and chaperone training.

However:

  • The practice had started to review staffing issues and introduce data management systems to ensure recruitment processes were completed and clinical and professional registration monitored. The practice was also updating the topics for mandatory training and beginning to monitor staff completion.

We rated the practice as inadequate for providing effective services because:

  • Some performance data was significantly below local and national averages.
  • The practice did not have processes to ensure an appropriate response when data indicated their performance was below the national and local averages in relation to health promotion and health outcome.

  • Systems were not in place to provide a failsafe and make sure non-urgent correspondence was dealt with appropriately and in a timely manner.
  • Systems to ensure all clinicians had ready access to up-to-date best practice clinical guidance were not in place.

We rated the practice as requires improvement for providing responsive services because:

  • Patients did not have ready access to a complaints policy.
  • The complaints policy provided inaccurate information.
  • The provider did not have oversight of all complaints because informal comments and concerns were not logged.

However

  • The practice organised and delivered services to meet patients’ needs, patients could access care and treatment in a timely way and the practice had identified areas where there were gaps in provision locally and had taken steps to address them.

We rated the practice as requires improvement for providing well-led services because:

  • The overall governance arrangements were not formalised and comprehensive.
  • Clear and effective processes were not in place to provide oversight for a number of systems for example, managing correspondence; data security or monitoring commissioned services.
  • While the practice had a clear vision, that vision was not supported by a measurable strategy.
  • A comprehensive audit programme was not in place.

We rated the population groups as follows:

Older people, people with long term conditions; vulnerable people and people with poor mental health as: requires improvement and working age people and families and young people as: inadequate.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way to patients.
  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to carrying on of the regulated activity.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Take steps to enable an audit of which staff had checked emergency medicines and equipment, ensure emergency medicines are replaced before they go out of date and complete a risk mitigation plan for emergency medicines not available in the emergency medicines kit.
  • Ensure all relevant staff have a clear understanding about the systems to manage safety alerts.
  • Action should be taken to support regular patient participation group meetings.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Requires improvement

Effective

Inadequate

Caring

Good

Responsive

Requires improvement

Well-led

Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Inadequate

Older people

Requires improvement

Working age people (including those recently retired and students)

Inadequate

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement